The premise that paramedics can safely and quickly determine who has an urgent medical problem discounts emergency physician expertise. Perhaps the most important service emergency physicians provide is the diagnostic acumen to rapidly determine which patient has an emergency. Do we really think that a paramedic with 10.5 additional hours of training (as under the Orange County, California, plan) can safely ascertain if an emergency exists, even for specified complaints?2 What about identifying significant hemarthrosis in a patient with seemingly minor extremity trauma who happens to have a coagulopathy? What about an apparent viral illness in an immunocompromised patient? The toothache that is a myocardial infarction? Emergency physicians complete medical school and a three- to four-year residency to master the crucial skill of considering and ruling out the worst case. If paramedics can safely identify these unusual but not infrequent problems in the field, then what is the value of an emergency medicine residency?
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ACEP Now: Vol 34 – No 06 – June 2015What about identifying significant hemarthrosis in a patient with seemingly minor extremity trauma who happens to have a coagulopathy? What about an apparent viral illness in an immunocompromised patient? The toothache that is a myocardial infarction? Emergency physicians complete medical school and a three- to four-year residency to master the crucial skill of considering and ruling out the worst case.
Paramedicine Won’t Solve ED Crowding or Cost Problems
The purported benefits of CP diversion programs are highly questionable. Although ambulance wall time is a worsening problem, it is unlikely that low-acuity patients contribute to this. Most EDs care for less-urgent patients in an efficient fast track. During busy times, ambulatory patients are triaged and moved to a waiting area, freeing the ambulance to return to service. Typically, only patients unable to ambulate or sit remain on a gurney. It is doubtful that many of these sicker patients can be safely diverted to alternative destinations.
Diverting 911 patients will not mitigate ED crowding; ED crowding is due to boarding. As emergency physicians know, the major contribution to ED boarding is the inability to disposition patients after the ED evaluation is complete. For admitted patients, it is because of bed availability. For discharged patients, delays in disposition are often due to insufficient follow-up resources. For these patients, CP programs will not improve the system; patients cannot be transported to other locations if an alternative destination does not exist or does not have the capability and willingness to evaluate and treat them. Simply changing the destination does not improve access to care; rather, it limits timely access to needed emergency care.
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One Response to “Opinion: Paramedicine Diversion Programs Pose Patient–Safety Risks”
June 28, 2015
David Persse, MD FACEPTom,
Great to see you in print! I liked your article, and I agree with much of what you said. I also liked Melissa Costello’s counterpoint, and in fact think you are both correct. “Community Paramedicine” is a poorly defined term in my opinion. Its implementation is as varied as the imagination. As it turns out, here in Houston my system has recently (Dec 2014) launched a hybrid version we call Emergency TeleHealth And Navigation (aka ETHAN) for an emergency physician based EMS diversion program. Google “ETHAN EMS Houston” if you are interested. To date we have triaged over 1300 patients with 80% not being transported by ambulance to hospital. About 40% go by cab to a hospital, but the rest are mostly referred to a project member local clinic or given home health instruction.
Anyway, good to read your thoughts.
An old friend,
Dave